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208151Orig1s000 CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 208151Orig1s000 MEDICAL REVIEW(S) CLINICAL REVIEW of NDA 208-151 Application Type Original NDA Application Number(s) 208-151 Priority or Standard Standard Review Submit Date(s) 2/12/2016 Received Date(s) 2/12/2016 Division / Office Division of Transplant and Ophthalmology Products, Office of Antimicrobial Products Reviewer Name(s) Wiley A. Chambers, MD Review Completion Date September 13, 2016 Established Name Atropine ophthalmic solution Therapeutic Class Anticholinergic Applicant Alcon Research, Ltd 6201 South Freeway Fort Worth, TX 76134-2099 Proposed Indication(s) Cycloplegia Pupillary dilation Amblyopia (b) (4) Template Version: March 6, 2009 Reference ID: 3985196 Clinical Review Wiley A. Chambers, MD 2 NDA 208-151 Table of Contents 1 RECOMMENDATIONS/RISK BENEFIT ASSESSMENT..........................................4 1.1 Recommendation on Regulatory Action ..............................................................4 1.2 Risk Benefit Assessment .....................................................................................4 1.3 Recommendations for Post marketing Risk Evaluation and Mitigation Strategies .............................................................................................................................4 1.4 Recommendations for Post marketing Requirements and Commitments ...........4 2 INTRODUCTION AND REGULATORY BACKGROUND .........................................4 2.1 Product Information .............................................................................................4 2.2 Tables of Currently Available Treatments for Proposed Indications....................5 2.4 Important Safety Issues with Consideration to Related Drugs ............................5 2.5 Summary of Presubmission Regulatory Activity Related to Submission .............5 3 ETHICS AND GOOD CLINICAL PRACTICES..........................................................5 3.1 Submission Quality and Integrity .........................................................................5 3.2 Compliance with Good Clinical Practices ............................................................6 3.3 Financial Disclosures...........................................................................................6 4 SIGNIFICANT EFFICACY/SAFETY ISSUES RELATED TO OTHER REVIEW DISCIPLINES.............................................................................................................7 4.1 Chemistry Manufacturing and Controls ...............................................................7 4.2 Clinical Microbiology ............................................................................................8 4.3 Nonclinical Pharmacology/Toxicology .................................................................8 4.4 Clinical Pharmacology .........................................................................................9 4.4.1 Mechanism of Action .....................................................................................9 4.4.2 Pharmacodynamics.......................................................................................9 4.4.3 Pharmacokinetics ..........................................................................................9 5 SOURCES OF CLINICAL DATA.............................................................................10 5.1 Tables of Studies/Clinical Trials.........................................................................10 5.2 Review Strategy and Linkage (Bridge) to Proposed Product ............................13 5.3 Discussion of Representative Individual Studies/Clinical Trials.........................14 6 REVIEW OF EFFICACY ..........................................................................................15 6.1 Mydriasis and Cycloplegia .................................................................................15 6.2 Treatment of Amblyopia.....................................................................................27 6.3 (b) (4) ..........................................................................................29 7 REVIEW OF SAFETY..............................................................................................36 7.1 Methods .............................................................................................................36 7.1.1 Studies/Clinical Trials Used to Evaluate Safety ..........................................36 7.1.2 Categorization of Adverse Events...............................................................36 7.2 Adequacy of Safety Assessments .....................................................................36 Reference ID: 3985196 Clinical Review Wiley A. Chambers, MD 3 NDA 208-151 7.2.1 Overall Exposure at Appropriate Doses/Durations and Demographics of Target Populations ......................................................................................36 7.2.2 Explorations for Dose Response.................................................................36 7.2.3 Special Animal and/or In Vitro Testing ........................................................36 7.3 Major Safety Results..........................................................................................36 7.3.1 Deaths .........................................................................................................36 7.3.2 Nonfatal Serious Adverse Events................................................................37 7.3.3 Dropouts and/or Discontinuations ...............................................................37 7.3.4 Significant Adverse Events..........................................................................37 7.4 Supportive Safety Results .................................................................................38 7.4.1 Common Adverse Events............................................................................38 7.4.2 Laboratory Findings.....................................................................................38 7.4.3 Vital Signs ...................................................................................................38 7.4.4 Electrocardiograms (ECGs) ........................................................................38 7.4.5 Special Safety Studies/Clinical Trials..........................................................38 7.4.6 Immunogenicity ...........................................................................................38 7.5 Other Safety Explorations..................................................................................38 7.6 Additional Safety Evaluations ............................................................................38 7.6.1 Human Carcinogenicity ...............................................................................38 7.6.3 Pediatrics and Assessment of Effects on Growth .......................................39 7.6.4 Overdose, Drug Abuse Potential, Withdrawal and Rebound ......................39 7.7 Summary of Safety ............................................................................................39 8 LABELING .................................................................................................................40 Reference ID: 3985196 Clinical Review Wiley A. Chambers, MD 4 NDA 208-151 1 Recommendations/Risk Benefit Assessment 1.1 Recommendation on Regulatory Action NDA 208-151, atropine ophthalmic solution, 1%, an anticholinergic is recommended to be approved for use in creating pupillary dilation (mydriasis), cycloplegia, and for penalization of the healthy eye in the treatment of amblyopia. (b) (4) 1.2 Risk Benefit Assessment Pupillary dilation and cycloplegia impair visual function. When multiday pupillary dilation is required and/or pupillary dilation in the setting of ocular inflammation is required, the benefits outweigh the risks associated with the use of atropine. These risks are based on its known action as anticholinergic pharmacologic action in an otherwise normal individual. When maximal cycloplegia is required in the setting of an ophthalmic examination or in the treatment ocular inflammation, the benefits of the use of atropine outweigh the known and potential risks. The benefits outweigh the risks when atropine ophthalmic solution is used for ocular penalization as an alternative to ocular penalization by patching in the treatment of amblyopia. 1.3 Recommendations for Post marketing Risk Evaluation and Mitigation Strategies Routine monitoring is recommended. 1.4 Recommendations for Post marketing Requirements and Commitments There are no recommended post marketing requirements. 2 Introduction and Regulatory Background 2.1 Product Information Atropine ophthalmic solution has been used for pupillary dilation and cycloplegia for over 100 years. Reference ID: 3985196 Clinical Review Wiley A. Chambers, MD 5 NDA 208-151 2.2 Tables of Currently Available Treatments for Proposed Indications Drug Substance Duration (normal Action Subject of an individual) approved application Phenylephrine ~ 4 hours Mydriasis Yes Tropicamide ~ 4 hours Mydriasis & Cycloplegia Yes Cyclopentolate ~ 12 hours Mydriasis & Cycloplegia Yes Scopolamine ~ 72 hours Mydriasis & Cycloplegia No Homatropine ~ 48 hours Mydriasis & Cycloplegia No Atropine ~14 days Mydriasis, Cycloplegia, Yes and in the treatment of amblyopia 2.3 Availability of Proposed Active Ingredient in the United States Atropine ophthalmic solution is currently marketed by the applicant and a number of other manufacturers without an approved new drug applications. Akorn’s atropine
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